Client Intake

Emergency Contact (Name)*

Emergency Contact Number*

Emergency Contact Relationship*

What brings you to Sex and Intimacy Coaching? (Please share briefly what you'd like to explore or work on.)*

What are your current goals for this work?*

Do you have prior experience with therapy, coaching, or personal development work?*

Yes

If yes, briefly describe:

How would you describe your relationship to your body and emotions?*

Are you currently in a relationship(s)?*

Yes

If yes, how would you describe it?

What are your desires, challenges, or curiosities in your relationships or intimacy?*

Do you have any concerns, fears, or boundaries you would like me to be aware of as we work together?*

Have you experienced trauma, stress, or events that have impacted your relationship with your body, intimacy, or sexuality?*

Yes

If yes, please share only what feels comfortable:

Do you have any physical conditions, injuries, or sensitivities that I should know about?*

Do you practice any form of mindfulness, movement, or bodywork (e.g., yoga, dance, meditation)?*

What are your expectations or hopes for our sessions together?*

Do you have specific modalities or practices you are interested in exploring (e.g., touch, guided visualization, movement)?*

Are there any specific boundaries or preferences you’d like to share?

I understand that Somatic Sex and Intimacy Coaching may include verbal and experiential practices designed to help me connect with my body, emotions, and desires. I understand that my participation is voluntary, and I can set boundaries or stop at any time.*

Yes I understand.